Sliabh Mis Mental Health Admission Unit, University Hospital Kerry

110 Pages·2017·1.3 MB·English

by  Susan Finnerty

Sliabh Mis Mental Health Admission Unit, University

Hospital Kerry

ID Number: AC0055

2017 Approved Centre Inspection Report (Mental Health Act 2001)

Sliabh Mis Mental Health Admission Approved Centre Type: Most Recent Registration Date:
Unit, University Hospital Kerry Acute Adult Mental Health Care 01 March 2017
Rathass

Tralee

Co Kerry

Conditions Attached: Registered Proprietor: Registered Proprietor Nominee:

Yes HSE Ms Sinéad Glennon, Head of Mental
Health Services - Cork & Kerry

Inspection Team: Inspection Date: Previous Inspection Date:

M arianne Griffiths, Lead Inspector 20 – 23 June 2017 11 – 14 October 2016

Noeleen Byrne
Inspection Type:
Mary Connellan
Unannounced Annual Inspection
David McGuinness
Donal O’Gorman

The Inspector of Mental Health Services: Date of Publication:

Dr Susan Finnerty MCRN009711 9 November 2017

COMPLIANCE RATINGS 2017

RULES AND PART 4 OF THE

REGULATIONS MENTAL HEALTH ACT 2001 CODES OF PRACTICE
1
1
10
2
2
20
1 4

Compliant

Non-compliant
Not applicable
RATINGS SUMMARY 2015 – 2017

Compliance ratings across all 41 areas of inspection are summarised in the chart below.

Chart 1 – Comparison of overall compliance ratings 2015 – 2017

Not applicable Non-compliant Compliant
45
40
35
30 22 22
25 31
20
15
16 15
10
7
5
3 3 4
0
2015 2016 2017

Where non-compliance is determined, the risk level of the non-compliance will be assessed. Risk ratings
across all non-compliant areas are summarised in the chart below.

Chart 2 – Comparison of overall risk ratings 2015 – 2017

Low Moderate High Critical
18
16
14 2
12 8
10 6
8
6
3 5
5
4
3
2
3
2
1
0
2015 2016 2017

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Contents
1.0 Introduction to the Inspection Process ............................................................................................ 5
2.0 Inspector of Mental Health Services – Summary of Findings .......................................................... 7
3.0 Quality Initiatives ........................................................................................................................... 11
4.0 Overview of the Approved Centre ................................................................................................. 12
4.1 Description of approved centre ............................................................................................. 12
4.2 Conditions to registration ...................................................................................................... 12
4.3 Reporting on the National Clinical Guidelines ....................................................................... 13
4.4 Governance ............................................................................................................................ 13
5.0 Compliance ..................................................................................................................................... 14
5.1 Non-compliant areas from 2016 inspection .......................................................................... 14
5.2 Non-compliant areas on this inspection ................................................................................ 15
5.3 Areas of compliance rated Excellent on this inspection ........................................................ 15
6.0 Service-user Experience ................................................................................................................. 16
7.0 Interviews with Heads of Discipline ............................................................................................... 17
8.0 Feedback Meeting .......................................................................................................................... 18
9.0 Inspection Findings – Regulations .................................................................................................. 19
10.0 Inspection Findings – Rules .......................................................................................................... 63
11.0 Inspection Findings – Mental Health Act 2001 ............................................................................ 68
12.0 Inspection Findings – Codes of Practice ....................................................................................... 71
Appendix 1: Corrective and Preventative Action Plan ........................................................................... 80

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1.0 Introduction to the Inspection Process

The principal functions of the Mental Health Commission are to promote, encourage and foster the
establishment and maintenance of high standards and good practices in the delivery of mental health
services and to take all reasonable steps to protect the interests of persons detained in approved centres.

The Commission strives to ensure its principal legislative functions are achieved through the registration and
inspection of approved centres. The process for determination of the compliance level of approved centres
against the statutory regulations, rules, Mental Health Act 2001 and codes of practice shall be transparent
and standardised.

Section 51(1)(a) of the Mental Health Act 2001 (the 2001 Act) states that the principal function of the
Inspector shall be to “visit and inspect every approved centre at least once a year in which the
commencement of this section falls and to visit and inspect any other premises where mental health services
are being provided as he or she thinks appropriate”.

Section 52 of the 2001 Act states that, when making an inspection under section 51, the Inspector shall

a) See every resident (within the meaning of Part 5) whom he or she has been requested to examine
by the resident himself or herself or by any other person.
b) See every patient the propriety of whose detention he or she has reason to doubt.
c) Ascertain whether or not due regard is being had, in the carrying on of an approved centre or other
premises where mental health services are being provided, to this Act and the provisions made
thereunder.
d) Ascertain whether any regulations made under section 66, any rules made under section 59 and 60
and the provision of Part 4 are being complied with.

Each approved centre will be assessed against all regulations, rules, codes of practice, and Part 4 of the 2001
Act as applicable, at least once on an annual basis. Inspectors will use the triangulation process of
documentation review, observation and interview to assess compliance with the requirements. Where non-
compliance is determined, the risk level of the non-compliance will be assessed.

The Inspector will also assess the quality of services provided against the criteria of the Judgement Support
Framework. As the requirements for the rules, codes of practice and Part 4 of the 2001 Act are set out
exhaustively, the Inspector will not undertake a separate quality assessment. Similarly, due to the nature of
Regulations 28, 33 and 34 a quality assessment is not required.

Following the inspection of an approved centre, the Inspector prepares a report on the findings of the
inspection. A draft of the inspection report, including provisional compliance ratings, risk ratings and quality
assessments, is provided to the registered proprietor of the approved centre. Areas of inspection are
deemed to be either compliant or non-compliant and where non-compliant, risk is rated as low, moderate,
high or critical.
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COMPLIANCE, QUALITY AND RISK RATINGS

The following ratings are assigned to areas inspected. COMPLIANCE RATINGS are given for all areas

inspected. QUALITY RATINGS are given for all regulations, except for 28, 33 and 34. RISK RATINGS
are given for any area that is deemed non-compliant.

COMPLIANCE QUALI TY RISK

EXCELLE NT

COMPLIANT

SATISFACTORY LOW

REQUIRES MODERATE

IMPROVEMENT
NON -
COMPLIANT
HIGH
INADEQUATE

CRITICAL

The registered proprietor is given an opportunity to review the draft report and comment on any of the
content or findings. The Inspector will take into account the comments by the registered proprietor and
amend the report as appropriate.

The registered proprietor is requested to provide a Corrective and Preventative Action (CAPA) plan for each
finding of non-compliance in the draft report. Corrective actions address the specific non-compliance(s).
Preventative actions mitigate the risk of the non-compliance reoccurring. CAPAs must be specific,
measurable, realistic, achievable and time-bound (SMART). The approved centre’s CAPAs are included in the
published inspection report, as submitted. The Commission monitors the implementation of the CAPAs on
an ongoing basis and requests further information and action as necessary.

If at any point the Commission determines that the approved centre’s plan to address an area of non-
compliance is unacceptable, enforcement action may be taken.

In circumstances where the registered proprietor fails to comply with the requirements of the 2001 Act,
Mental Health Act 2001 (Approved Centres) Regulations 2006 and Rules made under the 2001 Act, the
Commission has the authority to initiate escalating enforcement actions up to, and including, removal of an
approved centre from the register and the prosecution of the registered proprietor.

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2.0 Inspector of Mental Health Services –

Summary of Findings

Inspector of Mental Health Services Dr Susan Finnerty

As Inspector of Mental Health Services, I have provided a summary of inspection findings under the headings

be low.

This summary is based on the findings of the inspection team under the regulations and associated
Judgement Support Framework, rules, Part 4 of the Mental Health Act 2001, codes of practice, service user
experience, staff interviews and governance structures and operations, all of which are contained in this
report.

Safety in the approved centre
There was a written policy in place in relation to the health and safety of residents, staff, and visitors. There
was also an associated corporate safety statement. Medication ordering, prescribing, storing and
administering was satisfactory. Resident identifiers were checked when staff administered medications,
undertook medical investigations, and provided other health care services.

On the first morning of the inspection, the approved centre exceeded its bed capacity by one: there were 35
residents present despite the fact that Sliabh Mis was registered to provide services to only 34 residents.
Brandon ward, which was the high observation unit, contained four beds but was not staffed at the time of
the inspection and not in use. The approved centre did not have a comprehensive risk management policy
in place. Requirements for the protection of children within the approved centre were not consistently
appropriate. On one occasion since the previous inspection, a child was nursed in a dormitory alongside
adult residents, however, the child had one-to-one nursing observation. Ligature anchor points were evident
and not minimised. Staff access to training had been limited due to the lack of availability of appropriate
facilities and equipment. Not all health care professionals were up to date with required training in the areas
of Fire safety, Basic Life Support, the management of violence and aggression and the Mental Health Act
2001.

AREAS REFERRED TO
Regulations 4, 6, 22, 23, 24, 26, 32, Rule Governing the Use of Seclusion, Code of Practice on the Use of Physical Restraint,
the Rule and Code of Practice on the Use of ECT, service user experience, and interviews with staff.

Appropriate care and treatment of residents
Registered medical practitioners assessed residents’ general health needs at admission and when indicated
by the residents’ specific needs, but not less than every six months. Adequate arrangements were in place
for residents to access general health services and be referred to other health services, as required. The
approved centre was compliant with Part 4 of the Mental Health Act 2001: Consent to Treatment. Apart
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from one policy deficit, the approved centre’s physical restraint processes met the relevant code of
practice.

The approved centre was non-compliant with individual care plans in 2015 and 2016 and was again non-
compliant in 2017. This non-compliance was risk rated as critical. The therapeutic services and
programmes provided by the approved centre did not meet the assessed needs of the residents. While
there were therapeutic programmes listed, about 50% of these programmes were regularly cancelled
because adequate and appropriate staffing resources were not available to provide the programmes. The
clinical nurse specialist was frequently reallocated from their role as activities nurse to provide one-to-one
nursing cover instead of facilitating therapeutic groups as planned.

The approved centre’s menus were not reviewed by a nutritionist or dietitian to ensure nutritional adequacy
in accordance with the residents’ needs. The needs of residents identified as having special nutritional
requirements were reviewed regularly by a dietitian but an evidence-based nutritional assessment tool was
not used in the approved centre. Although children were admitted, the approved centre was an adult
approved centre and was not suitable for the admission of children. Age-appropriate facilities and a
programme of activities appropriate to age and ability were not provided. Provisions were not in place to
ensure the safety of the child and to respond to a child’s particular needs as a young person in an adult
setting. Children were not always nursed in a single room, and one child was placed in an adult dormitory in
which adult residents were also being cared for. All child residents received constant one to one nursing care
throughout their time in the approved centre. Clinical files were not kept up-to-date or maintained in good
order. The approved centre was non-compliant with the Rules Governing the Use of Seclusion.

AREAS REFERRED TO
Regulations 5, 14, 15, 16, 17, 18, 19, 23, 25, 27, Part 4 of the Mental Health Act 2001, Rule Governing the Use of Seclusion
and Mechanical Means of Bodily Restraint, Rule Governing the Use of ECT, Code of Practice on Physical Restraint, Code of
Practice on the Admission of Children, Code of Practice on the Guidance for Persons working in Mental Health Services with
People with Intellectual Disabilities, Code of Practice on Admission, Transfer and Discharge, service user experience, and
interviews with staff.

Respect for residents’ privacy and dignity
Resident consent for searches was sought. Searches were implemented with due regard to the resident’s
dignity, privacy and gender; at least one of the staff members who was conducting the search was the same
gender as the resident being searched. Staff treated residents with respect and were observed to be
courteous and empathetic in their interactions with residents. All bathrooms, showers, toilets, and single
bedrooms had locks on the inside of the door and locks had an override function. Rooms were not
overlooked by public areas, observation panels on doors were fitted with opaque glass, and noticeboards
did not display any identifiable resident information.

Adequate toilet and washing facilities were not available in the seclusion room and the room had not been
maintained, and cleaned to ensure dignity, privacy, and resident safety, and there was a malodourous smell
in the seclusion room. Residents were observed wearing nightclothes during daytime hours during the
course of the inspection, however the reason why was not always documented in the residents’ individual
care plans.

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AREAS REFERRED TO
Regulations 7, 8, 13, 14, 21, 25, Rule Governing the Use of Seclusion, Code of Practice on Physical Restraint, Code of Practice
on the Guidance for Persons working in Mental Health Services with People with Intellectual Disabilities, service user
experience, and interviews with staff.

Responsiveness to residents’ needs
Residents were provided with menus providing a variety of wholesome and nutritious food choices and
meals were attractively presented in terms of texture, flavour, and appearance. Residents reported that the
quality of the food was good, apart from the vegetarian options, which were described as lacking in taste.
Secure facilities were provided for the safe-keeping of residents’ monies, valuables, personal property, and
possessions, as necessary. The approved centre did not maintain a signed property checklist detailing each
resident’s personal property and possessions. There was access to recreational activities appropriate to the
resident group profile, during the weekdays and at the weekend. Residents’ rights to practice religion were
facilitated within the approved centre, with facilities available to support their religious practices.

The approved centre used a new interview room as a visitor room to facilitate residents to meet their visitors
in private. Children could visit, if accompanied by an adult and supervised at all times. Residents had access
to their mobile phones and internet access was available under supervision. Residents were provided with
an information handbook at admission, and this included all necessary information on housekeeping
arrangements. Diagnosis-specific information and medication information sheets, as well as verbal
information, was provided to residents in a format that was aligned with the residents’ needs.

The premises were not maintained in good structural and decorative condition, were not clean, not
adequately ventilated and access to outdoor space was limited on a regular basis. This was a source of
concern for two residents and the peer advocate because its closure was reported as impacting negatively
upon service user quality of life, particularly in the warm weather.

AREAS REFERRED TO
Regulations 5, 9, 10, 11, 12, 20, 22, 30, 31, Code of Practice on the Guidance for Persons working in Mental Health Services
with People with Intellectual Disabilities, service user experience, and interviews with staff.

Governance of the approved centre
The approved centre was part of Community Healthcare Organisation (CHO) 4. It had a system of governance
in place at each level of the organisation. The approved centre was represented at a Risk Management Group
meeting at CHO 4 level and at the Mental Health Management Team monthly meeting.

Each department had established reporting systems in place, which included a line management and
escalation process. Responsibilities were clearly defined, and occupational therapy, social work, and
psychology staff had responsibilities outside the approved centre as well as their commitments to working
with residents of Sliabh Mis. Goals and strategic aims for each department were clearly stated. A system of
staff performance appraisal was established for the medical, social work, and psychology departments. All
disciplines fostered a system of supervision and peer review. Medical, nursing, and occupational therapy
departments each highlighted the issue of staff shortages as a potential risk. The involvement of the service
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user lead for mental health engagement and the peer support advocates in the approved centre facilitated
service user input into each department.

Operating policies and procedures required by the regulations were all reviewed within the required three-
year period. The operating policies and procedures of the approved centre were evidence-based and were
developed with input from clinical and managerial staff and in consultation with all relevant stakeholders,
including service users. The policies were not approved appropriately and were not communicated to all
relevant staff.

AREAS REFERRED TO
Regulations 26 and 32, interviews with heads of discipline, and minutes of area management team meetings.

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